European Journal of Cardiovascular Medicine

Periodontal disease which comprises gingivitis and periodontitis is a common oral infection that affects the tissues that surround and support teeth. When gingivitis, which is characterised by haemorrhaging swollen gums, and pain, fails to be managed, it can develop into periodontitis, which results in the loss of the supporting bone and periodontal adhesion.^{1, 2} The 11th most common ailment worldwide, according to the Global Burden of Disease Study (2016), was severe periodontal disease.³ Worldwide estimates of the prevalence of periodontal disease range from 20% to 50%. It is one of the main reasons for tooth loss, which can have an adverse effect on quality of life, self-confidence, mastication, and aesthetics. In 2016, there were 3.5 million years lived with disability (YLD) due to periodontal diseases worldwide.³ There was a 57.3% rise in the worldwide burden of periodontal disease between 1990 and 2010.⁴ 2010 worldwide loss of productivity due to severe periodontitis was estimated to be US 54 billion per year. The global prevalence of periodontal disease is expected to increase in coming years due to growth in the aging population and increased retention of natural teeth due to a significant reduction in tooth loss in the older population.⁵

The present investigation was designed as an observational study, carried out at Department of Periodontics and Implantology, Hazaribagh College of Dental Sciences and Hospital. The flow chart shows the selection of patients for the study (Figure 1). After inclusion in the study, patients underwent a clinical examination of their teeth and implants, and radiographs were only obtained if indicated from a clinical point of view. All subjects provided informed consent for inclusion before they participated in the study.

                                                    Figure 1. Flowchart of screening of patients

• Two subgroups of patients were identified: "smokers" and "former smokers/non-smokers." Patients who had given up smoking at the time of implant installation and had not smoked for at least the previous five years were classified as former smokers. Utilising a traditional periodontal probe, the full mouth bleeding score (FMBS), gingival recessions (GR), clinical attachment level (CAL), probing pocket depths (PPD), and full mouth plaque index (FMPS) were recorded for each patient.
• Depending on radiographs, the surgical research site was determined to be the location of the implant with the most bone loss. For evaluation, the two distinct categories were formed up of a <2 width of the keratinized mucosa (masticatory mucosa) at the implants, buccal and lingual in the lower jaw, and buccal in the maxilla.
• Radiological results and clinical data were used to assess periodontal health and the severity of the illness. Clinically and radiological evidence were used to diagnose peri-implant health, peri-implant mucositis, and peri-implantitis.
• Two examiners assessed the radiographs and measured all clinical indicators. 95% of examiners agreed within 1 mm of each other.
• In order to evaluate the Implant Disease Risk Assessment (IDRA), the following variables were considered: frequency of SPT; RM-bone (distance between restoring margin and marginal bone crest); BOP (%); PPD 5 mm; bone level/age (BL/Age); “perio vulnerability,” via staging and scoring; and the restoration's variables (cleanable, supra- or subgingival poor fit, excess cement, not cleanable).
• Radiographic examinations were performed to obtain a standard immediately after implant surgery.
• The implant thread for the Straumann® tissue-level implant Standard and Standard Plus is 1 mm at implants with a diameter of 3.3 mm. All other implants of those two types have an implant thread of 1.25 mm.

Statistical Analysis

Mainly descriptive statistics were obtained, including descriptive summary statistics with the mean and a 95% confidence interval (95% CI), standard deviation (SD), and median. Associations between implant specific outcome “% of BOP at implants” (% positive sites at implants) and teeth-related measurements, including “% of BOP at teeth” (% positive sites at teeth) or “% of residual pockets at teeth    5 mm”, were analyzed with Kendall’s Tau-b, in which a causal relationship could not be readily assumed.

Table 1. Variables included in the final multilevel model predicting peri-implant condition at the implant level

Table 2. Demographic data of patients at examination time point.

During moment of inserting, patients ranged in age from 32 to 76 years (mean 55.8 years (SD 9.27)), with 43 of them being female (Table 2). All of the patients were in good general health. Prior to receiving an implant, each patient underwent periodontal treatment, and when the patient's PPD was greater than 5 mm, no implant was placed. 11 individuals were smokers, whereas the remaining patients either did not smoke or had not smoked since their implantation. Among the patients with persistent pockets was the entire smoker population.

A total of 39 individuals were identified with stage IV generalised periodontitis and 44 patients with generalised stage III periodontitis at the examination time point. At the assessment time point, the mean FMPS was 25.3% (SD 13.43) and the mean FMBS was 16.2% (SD 9.10). Every patient was qualified to take part in a routine maintenance programme; however, 12 patients (14.5%) chose not to utilise this chance to keep their periodontal and peri-implant health. There were no locations of 4 mm demonstrating BOP in the 12 patients with successfully treated stable periodontitis at this particular time point. Nine patients had received successful treatment; nevertheless, they still had some gingival irritation, and 62 patients had residual pockets with BOP and PPD of 5 mm. The mean number of residual teeth was 18.7 (SD 4.88) teeth/patient (range 7–27; median 19).

Table 3. The distribution and combination of implants among patients in relation to peri-implant diagnosis

Table 4. Implant characteristics at examination time point.

BOP was measured at six sites around each implant (mesio-vestibular, vestibular, disto-vestibular, mesio-oral, oral, and disto-oral). Interestingly, the frequency of BOP was systematically different, depending on the position of the site. At the disto-vestibular (mean frequency: 11.2% [7.3 to 16.8]) and mesio-vestibular (13.7% [9.2 to 20]) measurements, a noticeably lower number of positive sites than those obtained from all four remaining measurement points (mean frequency 24.3 [20.9 to 28.4] was found (multilevel binary logistic regression; comparisons p < 0.05..

The current long-term evaluation's findings indicate that among maintained properly individuals who already had treatment for progressive peri-odontitis, peri-implant disease was highly prevalent. These outcomes highlight the difficulties, especially for implant dentistry and periodontics-focused clinics, in maintaining the continuing oral wellness of stage III/IV patients who have had dental implants replaced. The current investigation has both advantages and disadvantages. The relatively homogeneous patient population is undoubtedly an advantage. Prior to the implants being placed, each patient had previous episodes of successfully treating periodontitis. The exact same kind of implant was used, and all implants were fitted by the same specialist in the same dentist office underneath the same circumstances. The majority of patients participated in an individual SPC program and were non-smokers or past-smokers. The length of the follow-up (5–17 years) can be seen as another advantage. On the other hand, these facts limit the generalizability of the results, as not all patients affected by the sequelae of stage III/IV periodontitis can benefit from such an ideal setting.

Although peri-implant mucositis is curable, peri-implantitis is thought to be at danger when it persists.^7,8 Only 20 implants (24.1%) in the current investigation showed peri-implant health at all, whereas 79 implants (37.1%) were identified as such (Table 2). According to the most current EFP S3 level guideline, "Prevention and Treatment of Peri-Implant Diseases," 43–47% of patients had peri-implant mucositis, and 20–22% had peri-implantitis.⁷ At the patient level, the current investigation found that peri-implant mucositis was more common (66.3%) and peri-implantitis was less common (9.6%). This could occur as a result of the small numbers of patients in the current trial who were noncompliant and smokers. Each patient made the same visit surgeon/periodontist over many years; thus, BOP on an implant/tooth would, of course, be treated according to the state of the art. Moreover, the specialized practice had a clear opinion about smoking; the population from this practice may thus be influenced by or selected according to this technique.

Merely 13% of the patients in this trial were smokers; the remaining individuals were either non-smokers or had stopped smoking before to implantation and had not resumed.

Inflammation and bone loss accelerate the remodelling process, with peri-implantitis being diagnosed in 9.6% of the implants included in this research, with peri-implant mucositis accounting for the majority of cases (66.3%). As also mentioned in the Evidence-Based Guideline for Peri-Implant Therapy from the XVIII European Workshop on Periodontology, this highlights the significance of SPT on a regular basis.^7,9 Seventy-one of the eighty-three patients who participated in the research took advantage of the chance to visit the dental office on a regular basis, making up the majority of the patients.  The number of patients not keeping their appointments for SPT was relatively low, and no conclusion as to the influence of regular maintenance on the results was possible.

• While most of the individuals studied had demonstrated strong compliance with routine SPC, the current long-term analysis's findings indicate a significant frequency of peri-implant disease in those who had received treatment for progressive periodontitis. In addition to clinics that specialise in periodontics and implant-supported dentistry, such results highlight the significant obstacles associated with the long-term maintenance of oral health in stage III/IV patients rehabilitated with dental implants.

1. Newman M. G. Carranza’s Clinical Periodontology.Amsterdam, Netherlands: Elsevier Health Sciences; 2011.
2. World Health Organization. Oral Health.Geneva, Switzerland: World Health Organization; 2018.
3. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211–59.
4. Sanz M. European workshop in periodontal health and cardiovascular disease. European Heart Journal Supplements. 2010;12(Suppl B):p. B2. 
5. Misch, C.E.; Perel, M.L.; Wang, H.-L.; Sammartino, G.; Galindo-Moreno, P.; Trisi, P.; Steigmann, M.; Rebaudi, A, Palti, A, Pikos, M.A.; et al. Implant Success, Survival, and Failure: The International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008,17, 5–15.